Psychoanalytical Investigation of Clinical Phenomena in Psychosis, in the Pandemic Context of COVID-19

Recent international studies on the impact of the COVID-19 pandemic on mental health motivated the writing of this article. The article presents the preliminary results of the research conducted by me at the Laboratory of Fundamental Psychopathology in Studies on Subjectivity and Humanitarian Emergencies, of the Graduate Program in Psychology at the Federal University of Rio de Janeiro (UFRJ, Brazil). There were five months of theoretical survey of the theme based on the following research problem: what is the impact of social isolation and uncertainty about the future, on the functioning of the self in psychosis? The purpose of the article is to expose the results of the first phase of research on the topic, which consisted of a systematic review of the scientific literature on the topic of humanitarian emergencies, locating pandemics in this classification and specifically asking about the impact of COVID-19 on disorders related to the functioning of the self in psychosis, I finally maintain the relevance of developing a clinical protocol for the psychological approach of these situations, within the framework of the impacts of the COVID-19 pandemic about subjective functioning.


Introduction
The objective of the article is to present the theoretical survey carried out between March and August 2020 with the research project "Psychoanalytic Investigation of Clinical Phenomena linked to Psychosis, in the Pandemic Context of How to cite this paper: de Lima, C. H. (2020). Psychoanalytical Investigation of Clinical Phenomena in Psychosis, in the Psychology COVID-19", developed in the Graduate Program in Psychology, Federal University of Rio de Janeiro (UFRJ, Brazil).
The high infectious potential and the degree of lethality of COVID-19 (coronavirus disease) is widely known. However, the current stage of scientific knowledge is still moving towards discovering the most accurate drugs for the cure of COVID-19 and developing a vaccine for its prevention. Thus, until now, social isolation and quarantine have been the most accurate methods for preventing . The scientific literature has raised the impacts of the pandemic on the population's life routine: difficulty in accessing health services to care for clinical health problems not directly linked to COVID-19, difficulties in accessing means of transportation and maintenance of work routines, unemployment, financial difficulties (Hao, Tan, Jiang, Zhang, Zhao et al., 2020). Such impacts associated with the situation of sudden social isolation and the difficulty of projecting a horizon of normality in the routine of life have also affected mental health to the point of being considered as possible predictors for the occurrence of psychic disorders (Thackur and Jain, 2020). Thus, depression, anxiety, distress, sleep and eating disorders, suicidal ideation, are some well-known examples of the possible effects of a humanitarian emergency of the magnitude of the COVID-19 pandemic on the mental health of populations (Ministério da Saúde, 2020; Lima et al., 2020;Zhang, Wu, Zhao, and Zhang, 2020).
Since 1996, I have investigated the psychic processes at play in triggering psychopathological phenomena such as: use of psychoactive substances, depression, cutting and anorexia. The clinical observation of the dynamics of these phenomena led me to formulate the psychoanalytical hypothesis that the psychic etiology of these psychopathological phenomena is correlated with: 1) The formation of a defense against repressed content, through character.
The recognition of this defense provides elements for the formulation of the diagnosis of neurosis underlying the psychopathological phenomena mentioned above.
2) The disturbance in the process of constitution of the self from the unification of the drives, which pressures the psychic functioning to form an imaginary identification. The recognition of this disturbance in the self provides elements for the formulation of the diagnosis of psychosis underlying the psychopathological phenomena mentioned above.
The development of this hypothesis took place in the light of the concepts of repression and foreclosure, making it possible to locate when, for example, food refusal in anorexia or the use of psychoactive substances in chemical dependence, respond to a psychic conflict or when they result directly from the rejection process or foreclosure. The study of clinical cases of patients with these psychopathological phenomena, at the Applied Psychology Service of Federal Fluminense University (UFF, Volta Redonda Campus, Brazil) has allowed to verify the research hypothesis, and to elaborate a model of construction of the clinical case, from the following steps: Psychology 1) Precise delimitation of psychopathological phenomena taking as a criterion the distinction between character and imaginary identification from the collection of the following information from the patient: time of onset, if the outbreak of the phenomenon represented a milestone in the patient's life, delimiting a "before" and an "after", degree of association with psychosocial problems, disease trigger factors or associated life events, types of thinking, affects that the patient finds simultaneous to the onset of the psychopathological phenomenon and how the patient describes these phenomena.
2) Verification of the psychic conditions of constitution of the character or of the imaginary identification, based on the following criteria of recognition of the psychopathological phenomena in the first stage: if it is associated, to some degree, with a psychic conflict covered by the counter-investment that the character ensures against the drive, or cover up features of elementary phenomena.
3) Elaboration of a diagnostic hypothesis of psychosis or neurosis based on the recognition of the psychic process that underlies the presented phenomena: foreclosure or repression. Psychotic patients are more sensitive to environmental changes that directly affect the population's way of life. As they are patients who interpret the world as invasive, the central concern was to identify when patients interpreted social isolation measures as invasive and to stabilize the aggressive reactions resulting from this interpretation through a psychological protocol that privileged the patient's need for self-care through the use of a mask, hygiene care and preservation of isolation, and which aimed to minimize the certainty imposed by the delusional interpretation that social isolation represented an invasion of the self.
This clinical work motivated the development of a systematic review of the literature as well as some conceptual axes researched during the initial five months of the research. With the development of this research, I intend to build a protocol for the clinical treatment of psychotic patients in the context of the COVID-19 pandemic.

COVID-19
COVID-19 broke into the world in December 2019. Caused by the novel SARS-COv-2 virus, it had first been located as a regional epidemic, and first reported to the World Health Organization (WHO) on December 31, 2019. On January 30, 2020, WHO declared this new outbreak a public health emergency of international magnitude and importance-the highest level of WHO's alerts. On March 9, 2020, the Italian government announced severe emergency measures to contain the spread of the virus; soon after, on March 11, 2020, WHO declared COVID-19 as a pandemic. Since then, the world has been plagued by a new public health emergency, with the highest risk of contamination in the world. From Asia to Europe, to Africa and to North and Latin America, it took only three months for the world to succumb in a fast humanitarian emergency, given the degree of contamination of the virus and, in some cases, given the degree of severity that leads to death. Contamination occurs through contact with aerosols, and contaminated surfaces.

C. H. de Lima Psychology
The high degree of its transmission rate is worth to be emphasized: each person infected infects three other people, causing the overload of health systems until their collapse worldwide. Regarding the registration of the progress of contamination and the number of deaths, specifically in Brazil, even considering underreporting, official data indicate the growing increase in the number of cases. Thus, COVID-19 requires governments around the world to urgently develop public policies to reduce the effects of their contamination rate, as well as their most serious effects on the physical health of populations, from the beginning of infection until a possible death.
A solution for the COVID-19 pandemic in the world, through antiviral drugs and the development of vaccines, is still far away. But if, on the one hand, today, the world is still at this early stage in the field of physical health, on the other, there is a vast historical experience about the impact of humanitarian emergencies on the mental health of individuals, families and society. The current research is consistent with references from recent scientific literature on the correlation between the appearance of forms of psychological distress and the occurrence of events with a strong traumatic impact, especially regarding the functioning of the self, the regulation of affection and intersubjective relations (Briere & Spinazzola, 2005;Schmid et al., 2013;Cloitre et al., 2014), remaining consistent with the findings of the World Health Organization, WHO (2015) and Ministério da Saúde (2020), which will be presented below.

Mental Health in Humanitarian Emergencies
Epidemics, pandemics, wars, and natural disasters make up what the World Health Organization (WHO) defined as the framework for humanitarian emergencies. We know from the historical records of World War I the relevance of the concern with the outbreak of psychological suffering. A particularly important testimony is that of Freud, in two precise moments of his reflection on World War I. In the immediate context of this outbreak, he wrote "Reflections for the Times of War and Death" (Freud, 1915b(Freud, /1987, in which the author identified the change in attitude that war produced in the feeling of alienation from the world: "This attitude was far from being direct. To anyone who listened, we were naturally prepared to maintain that death was the direct result of life and that each of us owes nature a death and must expect to pay that debt. In short, death is natural, undeniable, and inevitable. However, we were used to behaving as if it were different. We revealed an undeniable tendency to put death aside, to eliminate it from life, trying to silence it. We even have a proverb 'To think of something as if it were death', that is, as if it were our own death, naturally. In fact, it is impossible to imagine death itself, or to say the same thing in another way: in the unconscious, each of us is convinced of its immortality" (Freud, 1915b(Freud, /1987). Psychology The accuracy in this analysis by Freud (1915bFreud ( /1987 about the impact of the War on subjectivity was remarkable, highlighting, in particular, the effect that a historical event of this magnitude had on the way human beings relate to their own finitude, what, later, Freud will call helplessness (Freud, 1926(Freud, [1925(Freud, ]/1987 leading the human being, from the narcissistic feeling of immortality to the imminent risk of destruction. In another moment, in "Lines of Progress of Psychoanalytic Technique", a conference held in the immediate context of the end of World War I, Freud (1919Freud ( [1918/1987) deepens this reflection, emphasizing how the consequences of a war are as important as the losses suffered. Stressing out that the misery of the world was deepening for humanity at that time, with the increase in cases of neurosis and the emergence of the feeling of anguish, Freud (1919Freud ( [1918/1987) had predicted, against any illusory optimism about the future, an epidemic equivalence of these forms of psychological distress to tuberculosis itself. And he was not mistaken.
Few more than a hundred years passed by and the speech by the Secretary-General of the United Nations (UN), António Guterrez, for the release of the report COVID-19 and the Need for Action on Mental Health, on May 13, 2020 does not separate himself from Freud's prediction by making it clear that, despite the COVID-19 pandemic being a physical health crisis, it produces a wide mental health crisis with the potential to worsen the world's misery: But the COVID-19 virus is not only attacking our physical health; it is also increasing psychological suffering. Grief at the loss of loved ones, shock at the loss of jobs, isolation and restrictions on movements, difficult family dynamics, uncertainty, and fear of the future. Mental health problems, including depression and anxiety, are some of the greatest causes of misery in our world (Guterrez, 2020).
In the specific case of epidemics/pandemics, the past forty years have witnessed how humanity has lived under the pressure of viral epidemics/pandemics with a strong impact on the mental health of individuals and communities. Table 1 summarizes a historical outline of the epidemics that broke out in the world since the 1980s.
Today, WHO documents accumulate information on the impact of humanitarian emergencies on mental health, as can be seen from the "Humanitarian 1) The worsening of preexisting psychological suffering-as is the case of moderate to severe depressive disorder, psychosis and harmful use of alcohol and other drugs.
2) The triggering of other forms of suffering, directly resulting from human exposure to humanitarian emergency conditions, as is the case of acute stress, grief, and post-traumatic stress disorder. The guide is also precise at the point where it warns to the fact that the set of pre-existing forms of psychological suffering, aggravated by emergency humanitarian situations, or triggered by them, impose a risk of self-harm and suicide. In this sense, the WHO (2015) itself has been establishing guidelines for the world population in order to reduce the anxiety of this period, also recommending the avoidance of certain coping strategies to deal with mental health situations-as is the case of use of psychoactive substances. They also corroborate the symptomatic picture already identified in the first quarter of a humanitarian emergency as presented by the Ministério da Saúde (2020)-"Mental health and psychosocial care in the COVID-19 Pandemic: General Recommendations". The document predicts similar reactions to occur in the COVID-19 pandemic, considering the start date of the first quarter in each region: 1) Fear: of becoming ill and dying from the disease; of infecting other people; of losing loved ones; losing livelihoods and income; of being socially excluded or for being a frontline professional.
2) Feelings of: uncertainty about the future, helplessness in the face of events, helplessness, loneliness, sadness, grief, and anxiety.
3) Behavioral changes: eating (having appetite), sleeping (insomnia or excessive sleep, nightmares). 4) Interpersonal conflicts with family members and at work. 5) Changes in thinking: recurring thoughts about the pandemic, the health of loved ones, death and dying.
The data indicate how the context of humanitarian emergencies is a condition of severe and additional stress to populations, directly impacting psychosocial well-being. However, the set of records accumulated on this impact did not prevent the mental health area from being one of the most neglected by governments.
The PAHO (2018) report, "The Burden of Mental Disorders in the Region of the Americas", shows that in Latin America, the non-Latin Caribbean, South America, Canada and the United States, mental health problems are responsible for more than 1/3 of the total number of disabilities. And yet, the report records how mental health financing was below what was necessary, not responding to coverage of needs in the area. Until 2018, the deficit ranged from 3 times more than current spending in high-income countries in the Americas to 435 times that in low-income countries in the region (PAHO, 2018). This explains the Psychology UN's concern to raise awareness among countries to reverse neglect and low investment in mental health services in favor of expanding psychosocial coverage for individuals, families and communities that have been affected by the impacts of uncertainty regarding the development of treatments and cure for COVID-19, uncertainty about the future, isolation and loss of loved ones that could not be elaborated through the collective ritual of mourning and funeral.
In the context of a pandemic of the magnitude of COVID-19-in which social isolation and, more radically the lockdown, are the main directions of prevention and treatment for the virus, and that uncertainty about the future is consolidated as a horizon in a scenario still without precise medicines-it is crucial to deepen the research on psychological suffering.
The study by Lai et al. (2020)  The study by Thackur & Jain (2020) is particularly significant and deserves to be highlighted for presenting a sample of case study references, in the year in which the impact of social isolation, the economic crisis and the stress and anxiety experienced by professionals stand out of health as predictive factors for triggering depression and suicide in the context of the COVID-19 pandemic.
Today, even after six months of the outbreak in Wuhan, we do not have a vast scientific literature on the precise extent of its impact on mental health. However, it is worth highlighting the expressions used by its residents when calling the situation of the pandemic: "end of the world" (Lima et al., 2020).
The use of these expressions shows how the language tries to circumscribe the traumatic dimension of a humanitarian emergency of the magnitude of the COVID-19 pandemic, and its effects on psychic functioning: end of the world and panic. Certainly, over the next few years, scientific production in the humanities and health technologies will bear witness to these impacts.

Etiology of Psychosis and Function of Delusion in Freud
The article presented some references that support the correlation between the emergence of forms of psychological distress and the occurrence of events with a strong traumatic impact, especially with regard to the functioning of the self, the Regarding psychoanalysis, the classic reading conducted by Freud (1911Freud ( /1987 assume to be the pathological product, is, in reality, an attempt to reestablish itself, a process of reconstruction" (Freud, 1911(Freud, /1987. This formulation was evaluated by the author himself as something that was never conceived in these terms before him and, in particular, before the elaboration of the concept of drive and the possibility of interrogating himself in the light of this concept about the etiology of the onset of psychosis (Freud, 1911(Freud, /1987. In fact, in "Psychoanalytical Notes on an autobiographical account of a case of paranoia (Dementia paranoides)", Freud (1911Freud ( /1987 will start from the uniqueness of Daniel Paul Schreber's clinical picture to, anchored in the theoretical framework of the first drive theory, support the hypothesis of a mixed picture of psychosis-defined by him as dementia paranoids-and to investigate its psychic etiology. Freud's (1911Freud's ( /1987 hypothesis was, then, elaborated to elucidate the etiology of the experience of the collapse of the world in schizophrenia. It is about the rejection of an intolerable idea for the Self and its projection for reality, so that "(…) what was internally abolished returns from without" (Freud, 1911(Freud, /1987). This hypothesis made it possible to isolate the process at play in triggering psychosis-rejection (Verwerfung)-and its effects on psychic functioning: 1) The retraction of the drive, previously invested in other people.
2) Your fixation on the self.
3) The outbreak of the delusion of persecution.
4) The occurrence of the delusion of greatness associated with the delusion of persecution.
In advancing towards elaborating a theory about the constitution of the self, in "About Narcissism: An Introduction", Freud (1914Freud ( /1982 re-asks the question regarding the fate of the drive, in schizophrenia and characterizes it in two stages: Time 1: Retraction of drive investment in relation to objects in the direction of the self, without substitution for fantasy (according to effects 1 and 2).
Time 2: Return to the logic of autoeroticism with the onset of hypochondriac phenomena-triggering of psychotic symptoms (which would indicate, not the outbreak of the delusion, but the very failure in the constitution of the self). Psychology In this sense, re-reading the theories about the Schreber case, conducted by Freud (1911Freud ( /1987, in the light of the theoretical advance of "About Narcissism: An Introduction (1914Introduction ( /1987)", the work of restoring the drive investment in objects by means of formation of delusion is secondary, characterized as delusion of greatness (megalomania) and delusion of persecution, and constituting attempts to drive the drive back to investment in objects.
Regarding to the text "The Unconscious", Freud (1915aFreud ( /1987 re-emphasizes the specific destiny assumed by the drive in the repression process in schizophrenia and makes a distinction regarding hysteria. In Appendix C of the text, Freud (1915aFreud ( /1987 distinguishes the representational field in the unconscious and in the preconscious-conscious system, placing the representation-of-thing in the unconscious and the representation-of-word and the representation-of-thing in the pre-conscious-conscious system. The location of the thing representation in the unconscious indicates that the object investment obeys the logic of the unconscious. And it is from this conceptual framework that Freud (1915aFreud ( /1987 elucidates the specificity of the defense process in psychoses and, especially, in the clinical form of schizophrenia: in it occurs the retraction of the drive investment of representations-of-thing and the advance about word-representations. Here, the emphasis is on the clinical effect of this retraction in the field of verbal expression, which undergoes a disorganization to the point of becoming totally incomprehensible. Taking as a reference a case attended by Victor Tausk, Freud (1915aFreud ( /1987 identifies in his logic the same working structure of the hypochondriac phenomena resulting from the retraction of the drive for autoeroticism: "Thus the schizophrenic oral manifestation exhibits a hypochondriac characteristic: it became if it "speaks of the organ" (Freud, 1915a(Freud, /1987).
The hypotheses of the rejection of the psychic representation and the retraction of the drive, formulated by Freud within the framework of the first drive theory, are not abandoned. But they will be thought in the light of the death drive theory from 1920 on. The crucial references for the understanding of the advance of a theorization about the specific psychic processes of psychosis are the texts "Neurosis and psychosis" (Freud, 1924a(Freud, /1987 and "The loss reality in neurosis and psychosis" (Freud, 1924b(Freud, /1987. In both references, Freud (1924aFreud ( /1987Freud ( , 1924bFreud ( /1987 argues that neurosis and psychosis translate the failure of the self to reconcile the drive imperative (death drive) and the demands of civilization. From this common failure, the author will define, in Neurosis and psychosis (Freud, 1924a(Freud, /1987, the specificity of psychic processes in neurosis and psychosis: in neurosis, the conflict between the instinctual imperative (death drive) and the civilization's demands appears in the form of an impasse between the id and the self; in psychosis, the conflict appears in the form of an impasse between the self and the outside world. Both psychic processes produce, in a second time, the loss of reality, and the difference lies in the solution: in neurosis, the solution to the loss of reality lies in the investment in fantasy; in psychosis, it lies in delirium. This is defined as resulting C. H. de Lima Psychology from the process of replacing the rejected reality, fulfilling the function of patching the loss of reality. From the set of references above, the conceptual axes that support Freud's theory on psychosis are extracted. They are: 1) The psychic process that constitutes psychosis: "(...) what has been abolished internally returns from without" (Freud, 1911(Freud, /1987. 2) The relevance of determining trigger conditions.
3) The hypothesis of the loss of reality because of the constitution of psychosis and the reparative function of delusion (Freud, 1911(Freud, /1987.
4) The irruption of the logic of hypochondriac phenomena in verbal expression, evidencing their subjection to the pulsional invasion (Freud, 1915a(Freud, /1987.
5) The recognition of the hegemony of drive functioning in the etiology of loss of reality, evidenced in neurosis and psychosis, and the specificity of the function of delusion in psychosis in relation to the formation of fantasy in neurosis (Freud, 1924a(Freud, /1987(Freud, , 1924b(Freud, /1987
2. Suggestibility: The person has a passive readiness to be influenced and an identification of an automaton type.
3. Presence of aggressive tendencies on the basis of passive readiness.

Mirror sign
The patient shows exacerbated concern with his image, examining himself long and often before reflecting surfaces. The patient has the experience of being side by side with the image and, suddenly, he may be filled with horror at something terrible on the surface of the mirror (himself). Detected in classical melancholic states and schizophrenia, but it is not uncommon in cases of ordinary psychosis. It has 2 stages: 1. Unceasing observation: The person experiences the enigmatic character of the image. He feels that a change has occurred, but he cannot account for what is unusual or abnormal. In this sense, incessant observation is a response to the more or less restless strangeness that the person experiences regarding the change that he identifies.
2. Autoscopy: the patient experiences the absence of half of his body, experiencing that someone like him takes his place.  (1949/1998), the theory about the formation of the self defining its constitution by identifying an imago that does not correspond to the condition of initial body fragmentation that affects all human beings in the initial stage of life. Situated in a concrete period of child development (between 6 and 18 months), the mirror stage formalizes how fragmentation finds in the external image, a fundamental alienation that will enable the creation of a gestalt.
This fundamental alienation in the external image depends on a word of recognition, a symbolic message, which comes from the other towards the fragmented body, and verified by Lacan (1949Lacan ( /1998 in the child's movement towards the adult's look or words that supports it. The constitution of the self includes an alterity, which is beyond the child, and which places for them and through language, the place from which they must identify themself with the image. In this sense, language plays a crucial role in the organization of the fragmented body: it promotes a narcissistic armor that unifies the body in an image. These findings by Lacan (1949Lacan ( /1998) provide a precise indication of the etiology of the alterations of the self in psychosis until its more radical regression to the fragmented body, as seen in schizophrenia: the fragility, the decline in the operability of this symbolic message that results in the pictures of body fragmentation and dissolution. Maleval (1996) reproduces Ostancow's example about a 21-year-old patient who suffered from autoscopy: Over the course of several years, he devoted himself to a thorough examination of his figure, spending entire hours in front of a mirror. (...) He believed, he said, to observe that the people around him noticed that he had a comical aspect, a tiny head, a narrow forehead, the whole structure of a chicken. He claimed to have heard it said about him that he had no nose, and when he returned to his home he looked at himself in the mirror and, in fact, it seemed to him that his nose had changed shape and that his forehead had become very narrow (Maleval, 1996: p. 633).
The clinical description above highlights the elements present in the onset of psychosis: the autonomy of language in its raw state, divorced from its status of message, meaning and directed to the patient's body, the disintegration of the body unit following the typical regression until the body fragmentation at the mirror stage.
The systematic review carried out in the initial five months of the survey allows us to consider that these elements in the light of the situation of the pandemic of COVID-19-with the exposure to the dangerousness imposed by the virus, the reduction of the possibilities of participating in society because of the social avoidance measures (from isolation to lockdown), uncertainty about the future-contribute to the worsening of cases of pre-existing psychosis to COVID-19. The continuity of the research will aim to verify, through clinical studies resulting from the virtual psychological care clinic project, the hypothesis that the pandemic situation exacerbates these typical elements of the functioning Psychology of psychosis (experience of raw language operating directly on the patient's body, bodily dissolution).
The set of references raised by the systematic review of the specialized literature on the topic, shows the place that psychoanalytic psychopathology has in contributing to the advancement of research in diagnosis and therapeutics of the psychopathologies of the self in psychosis, considering the humanitarian emergency situation.

Conclusion
According

Conflicts of Interest
The author declares no conflicts of interest regarding the publication of this paper.